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Detecting oral cancers in patients in their 50s and 60s has never been uncommon. But local dentists and doctors say finding it in younger patient populations has become a new norm.

Oral cancers driven by Human Papillomavirus are now the fastest growing oral and oropharyngeal cancers, according to the Oral Cancer Foundation website. And local health officials say they’ve seen a few more cases than usual.

Dr. Joehassin Cordero, FACS, professor, chairman and program director ofTexas Tech’s Health Sciences Center Department of Otolaryngology-Head & Neck Surgery, said less people are smoking and that has contributed to the decrease in the number of cases of oral cancers in the past two decades.

“In that same period, we have seen an increase in the HPV oropharyngeal cancer,” he said. “And oropharyngeal cancer — what it means it’s affecting the base of your tongue and tonsils.”

Dr. Brian Herring, a Lubbock dentist, chalks the increase up to increased awareness.

“I’m assuming probably for years and years and years it has affected the mouth but we didn’t know that,” he said. “As we get better at cellular diagnostics and molecular diagnostics, things like that, we’re finding that there is a large portion of cancers that do have an HPV component.”

What’s more alarming, said Dr. Ryan Higley, oral surgeon with West Texas Oral Facial Surgery, is it’s being diagnosed in younger people.

Higley said oral cancers are generally diagnosed between the ages of 55 and 65, mostly in women.

“With HPV-associated cancers, we see those four to 10 years before that,” he said. “It’s a younger patient population.”

Cordero said the oral cancers are often caused by exposure to HPV from years before.It starts with exposure to the HPV infection. One in four people in the United States are currently infected, according to the Centers for Disease Control and Prevention website.

“It’s truly considered a sexually transmitted disease,” Cordero said. “It has to do with not so much kissing, but oral sex.”

It’s passed on when somebody with an active lesion engages in sexual activities with another person, he said.

Nine out of 10 infections will disappear on their own, according to the CDC, but infections that linger for longer than about two years can lead to cancer.

“That doesn’t mean they’ll have cancer next week,” Cordero said.

Researchers are still trying to figure out why and how long after HPV exposure it takes for cancer to develop, he said.

“We don’t know the true mechanism because most of these people were not exposed a year ago,” he said. “They were not exposed six months ago. They were exposed a long time before that.”

When it does present, he said, there generally aren’t any noticeable symptoms.Because of that, it’s often diagnosed in later stages, Herring said.

“What we’re finding is because the demographic is changing, they’re not getting diagnosed as early because they’re not expecting to have this problem,” he said.

Screenings for oral HPV exist.

“The gold standard examination is your typical dental exam,” Herring said. If your dentist detects something unusual that might need further examination, he or she will make a referral to an oral surgeon.

Higley said oral HPV cancer presents as a lesion that looks like a kanker that won’t heal.

“However, cancerous lesions can have multiple presentations so that’s not exclusive,” he said. “So oftentimes, we’ll have a patient present with a hard nodule underneath their jaw line or in their neck. Sometimes they’ll just have red or white lesions within the mouth, hoarseness in their voice or difficulty swallowing. All those are things that need to be checked.”

The cancer seems to be more treatable, he said, but it’s hard to pinpoint why.

“We really don’t know if they’re more responsive to treatment because we’re treating a little bit younger patient population who is overall more healthy or if it’s inherant in the tumor itself,” Higley said.

Cordero said he hopes the HPV vaccine, which is recommended for both girls and boys 11 or 12 years old and people up to 26 years old, provides a measure of protection against the infection.

“We’re hoping in the next 10 to 20 years that head and neck cancer caused by HPV will be completely gone,” he said.

Australian researchers have developed a quick, low-cost blood test to detect the early signs of oral cancer. The diagnostic test examines the profile of small molecules called microRNA in the blood and can be done at the same time as other routine checks, such as for cholesterol.

At present, no routine screening tests for oral cancer are on the market. The researchers hope that a simple blood test could change that and, in doing so, help stem the global increase of various oral cancers.

About 300,000 new cases of oral cancer were reported globally in 2012, according to the researchers. The main barriers to treatment remain late detection and low disease awareness. Warning symptoms include pain, swelling, a hoarse voice, and difficulty swallowing — symptoms that are often dismissed or misdiagnosed as a common cold.

The test, called miLIFE, was developed by researchers Nham Tran, PhD, and doctoral candidate Samantha Khoury from the University of Technology, Sydney (UTS) Centre for Health Technologies. The blood-based test can be administered by healthcare providers to screen microRNA to reveal the oral cancer’s early warning signs. The turnaround time for the test is about 48 hours at present.

The levels of five specific microRNA molecules are detected with miLIFE and compared with those of healthy, noncancerous individuals. An overabundance or expression of these specific microRNAs would designate people at high risk for oral cancer. These patients would then be referred to a specialist for further examination.

“You don’t need a specialist to administer the test,” Khoury noted. “When you visit your GP [general practitioner] for routine checks of cholesterol, vitamin D, hemoglobin, and so on, the same blood sample can be used to check for the presence of microRNA biomarkers.”

The majority of oral cancer patients who go to the doctor have already developed an advanced lesion, but by then it is too late, Tran stated.

“At this stage, their diagnosis option is to undergo a tumor biopsy or a fine-needle aspiration, both highly invasive and painful procedures,” he noted. “We hope that through miLIFE we can provide early intervention to decrease the number who are diagnosed with oral cancer each year.”

The test is being filed under a UTS provisional patent, and Tran hopes it will be available within two to three years.

The technology, in development since 2006, has evolved via an ongoing collection of consenting cancer patient samples from surgeons based at several Sydney hospitals. The researchers collaborated with the Sydney Head and Neck Cancer Institute, the Cancer Council Australia, and Mount Sinai Hospital in New York.

Next the researchers plan to expand the project with the Vellore Christian Medical College Foundation in India. They targeted India because that country has the world’s highest rates of oral cancer, with 40,000 cases diagnosed annually.

“The introduction of a robust cancer screen will provide a platform for effective cancer management in low-resourced countries,” Tran noted.

A new “rinse and spit” test for oral cancer is capable of early detection of tumors across “a racially and ethnically diverse population,” according to results of a study conducted by the University of Miami Miller School of Medicine. Coinciding with Oral Cancer Awareness month, results from the largest oral cancer marker study of its kind in the U.S. were presented at the annual meeting of the American Association for Cancer Research in Washington, D.C. and the American Head and Neck Society annual meeting in Orlando, Florida.

The test, developed at the University of Miami Miller School of Medicine and exclusively licensed to Vigilant Biosciences, Inc. (Vigilant), will be available as a low-cost, point-of-care “rinse and spit” screening test for the early detection of oral cancer.

The study of 300 subjects, sponsored by the National Cancer Institute, employed a case-control design ensuring cases (oral cancer patients) and controls (volunteers without cancer) were similar with respect to other important factors such as tobacco and alcohol use, age and race. The study was conducted by principal investigator Elizabeth Franzmann, M.D., Associate Professor of Otolaryngology, at the University of Miami Miller School of Medicine and a member of the University’s Sylvester Comprehensive Cancer Center.

“There is a tremendous need for a simple and painless test for early detection of oral cancer because the majority of patients present in late stage when cure rates reach only 40 percent,” said Dr. Franzmann. “Since minority patients and those of low socioeconomic status suffer disproportionately from this disease, results of the study show that an easy to administer, noninvasive and inexpensive test can provide patients with limited access to care ready means to early intervention and screening.”

“We are building on the leading work of Dr. Franzmann and her colleagues to develop a low-cost, specific and easy-to-use test that enables early detection and reliably rules out cancer,” said Vigilant founder and Chairman Matthew H.J. Kim, J.D. “Vigilant’s product will be part of annual routine dental exams and will play an essential role in mass screening initiatives.”

Vigilant’s product, which is under development, consists of a low-cost, oral cancer-specific oral rinse test strip that provides an immediate and simple color change in the presence of certain levels of proteins clinically proven to be associated with early-onset of oral cancer – typically before a lesion is visually detected with a screening aid. Dental offices and public health screening facilities are seen as primary initial markets for the technology. The test can be applied to everyone, with particular emphasis on tobacco users, people who consume alcohol and people with human papillomavirus (HPV), and initially represents an approximately $600 million U.S. market opportunity and a multibillion dollar opportunity worldwide.

About 42,000 new cases in the U.S. and 640,000 people worldwide are diagnosed with oral cancer each year with more than half of those patients dying from the disease within 5 years of diagnosis due to late-stage diagnosis and intervention. Oral cancer treatment options include surgery, radiation and chemotherapy.

A new, noninvasive cytology test for oral cancer, ClearPrep OC, is being offered free to dentists. The test, aimed at “watch and wait” lesions, is less expensive than biopsies and less frightening for patients, according to Resolution Biomedical, the company that is commercializing it.

The chairside oral cancer test — which can be ordered directly from the company — is designed to be a diagnostic option for assessing lesions when a biopsy is not warranted or the patient fears getting a biopsy, according to Donald Williams, MD, chief medical officer of Resolution Biomedical.

The test involves a cyto-brush sampling method that measures gross changes in the nuclear DNA content of oral epithelial cells, providing information about the precancerous or cancerous state of a lesion, the company explained. The samples are sent to medical testing labs, and the report is sent to the dentist within four to five days, the same time frame as biopsies. Dentists send the samples to the company, which prepares the slides and sends them to labs, which prepare a diagnostic report for the dentists.

“It’s a way to triage patients where something may be suspicious but the patient is balking about getting a biopsy,” Dr. Williams told DrBicuspid.com. “It could be leukoplakia lesions or thrush instead of an indication of a neoplasm. It rules out biopsies without an invasive process.”

When dentists refer patients to periodontists to get biopsies of suspicious lesions, many patients don’t follow through on the recommendation because they find it a daunting procedure, Dr. Williams noted.

“Some patients think, ‘I’ve had this for years and it hasn’t killed me, so I don’t want to be biopsied,’ ” he said. “It’s kind of frightening to say you’re going to have a piece of meat cut out of your mouth.”

The most logical application is for worrisome lesions that are likely benign, Dr. Williams said.

Ongoing clinical trial
Resolution Biomedical conducted about five validation studies of the ClearPrep OC test in general practices over six months, Dr. Williams said. It is now being tested with Southern California dentists.

In addition, the test is in the second phase of a trial study with cancer patients in the City of Hope cancer research hospital in Duarte, CA. ClearPrep OC and saliva samples will be taken, and p16 stains will be done on the biopsy specimens. All the modalities then will be combined before a blind match is done. The company plans to do a joint publication based on the results with the University of California, Los Angeles, Dr. Williams said. The test was primarily designed for gynecologic cytology pap tests, but Resolution Biomedical realized it also had potential to detect oral cancer.

The company does not plan on doing an official launch of the product, which has no marketing restrictions since nongynecologic cytology tests are an established medical practice, according to Dr. Williams. As a result, the test does not require U.S. Food and Drug Administration clearance or need to be Clinical Laboratory Improvement Amendments (CLIA)-certified, he said.

While the test is being provided for free to dentists, patients and labs pay $60 to $125 — much less than biopsies, which range from $400 to $500, according to Dr. Williams. It is usually covered by insurance, and dentists can charge a collection fee for the process, including interpreting the final report, according to Dr. Williams. Company revenues will be derived from the testing labs it uses for analysis.

“Biopsies are invasive, expensive, and painful,” said company CEO Mike Friedl. “This is an intermediate way to rule out stuff while you’re still at the dentist rather than going to a specialist.”

The test is especially suitable if the condition is simply a treatable condition, such as a fungal change, and doesn’t require a trip to see a specialist, Friedl noted. Since the human papillomavirus (HPV) is now associated with many oral cancers, the company tests for it if the sample shows any degree of atypism.

Sol Silverman Jr., DDS, a professor of oral medicine in the University of California, San Francisco (UCSF) School of Dentistry and head of one of the oral medicine clinics at UCSF, called the ClearPrep test a good adjunctive diagnostic technique.

“Cytology has been around a long time, and it’s very high-quality,” Dr. Silverman told DrBicuspid.com. “Any technique that will accelerate the recognition of dysplasia is important. Early detection is still our best approach to good survival results.”

An NHS dentist who advised a patient to treat what turned out to be a life-threatening oral cancer with mouthwash is being sued for tens of thousands of pounds in damages.

Paula Drabble, 58, went to Pinfold Dental Practice, in Hattersley, Hyde, in June 2008 with concerns about a white lesion on her gum.

She was told by her dentist, Ian Hughes, it was nothing serious, a court heard.

Mrs Drabble of Mottram Moor, Mottram, Hyde, had five further appointments with Mr Hughes and was advised to ‘manage’ her complaint with mouthwash. She was eventually referred to hospital in April 2009, and ‘seriously invasive cancer’ diagnosed.

She had surgery, including removal of affected bone, followed by radiotherapy and chemotherapy.

She has now made a good recovery and has begun a High Court fight for damages, claiming Mr Hughes was negligent to have not spotted the cancer and referred her to hospital earlier. Timothy Briden, for Mrs Drabble, told the court his client had developed the patch on her gum some years earlier. The lesion was found to be benign by medics at the University Dental Hospital in Manchester and she was discharged in 2004 with a letter being sent to Mr Hughes, warning him to ‘re-refer if you notice or indeed Mrs Drabble notices any changes’.

Marcus Dignum, for Mr Hughes, denied that his client was at fault in failing to spot the cancer. He said: “Plainly the court will have every sympathy with Mrs Drabble in respect of her ordeal, as does Mr Hughes, but the allegations made against him are extremely serious from both a personal and professional standpoint. They are vigorously denied.

“In June 2008 the presence of the cancer would not have been detectable with the human eye, as its presence would have been at a cellular level only.”

LED Medical Diagnostics Inc. subsidiary LEDDental announced today that its VELscope Vx enhanced oral assessmentdevice will now be used by Chicago Otolaryngology Associates for oralmucosal abnormality assessment and when performing surgery on oral cancer patients.

According to Chicago Otolaryngology Associates’ Howard Kotler, MD,FACS, “We pride ourselves on embracing state-of-the-art technologies that allow us to provide the best patient care possible. The VELscopeVx may significantly enhance our ability to see the entire cancerous or precancerous lesion that needs to be excised, allowing us to minimize risk of additional unnecessary surgery.”

The VELscope Vx’s fluorescence visualization technology is the first approved by the FDA and Health Canada to help surgeons determine the surgical margins when excising cancerous and precancerous tissues. The technology is also approved to help dental and medical professionals discover cancerous and precancerous tissue that might not be apparent to the unaided eye.

The vast majority of the nearly 12,000 VELscope devices in use around the world are used by dental practices. Typically, when a suspicious lesion is detected by a dentist, the patient is referred to an oral surgeon or a periodontist for a surgical biopsy, which is then evaluated by an oral pathologist. If the biopsy sample is determined to be cancerous or precancerous, the patient is usually referred to an ENT head and neck surgeon for consultation and likely excision. VELscope technology was developed to address the problem of detecting all abnormal tissue, including that beneath the surface, as well as making it possible for dentists to discover early stage oral cancer, which requires less invasive treatment and has a significantly higher chance of survival than when the disease is detected in late stages.

“We applaud Dr. Kotler and Chicago Otolaryngology Associates forbeing one of the first Otolaryngology practices in the U.S. toincorporate VELscope’s potentially life-saving technology,” saidPeter Whitehead, founder and CEO of LED Dental and its parent, LEDMedical Diagnostics Inc. .

Imagine being able to treat a suspicious lesion on a patient’s tongue simply by applying a topical agent, waiting a few minutes, then exposing it to light from a handheld laser or light-emitting diode (LED) device.

Imagine being able to treat bacterial and fungal infections in the oral cavity, even periodontal disease, using this same approach.

That is the promise of photodynamic therapy (PDT), a minimally invasive technique that first came into medicine in the early 1900s and has been used to treat a plethora of medical conditions, including skin diseases, localized infections, age-related macular degeneration, and premalignant and malignant disorders.

“PDT in the oral cavity would utilize a photosensitizing compound and a light source to activate the compound,” explained Thomas Mang, PhD, research director in the Laser and Lightwave Research Center at the University at Buffalo School of Dental Medicine. “Traditionally, it has been used in head and neck lesions and oral lesions with a photosensitizer given intravenously. But in applications related to early oral lesions and those involving candida and oral species that may be involved with periodontal disease, we look to apply it topically.”

Distinct advantages
Mang has been investigating PDT disinfection of oral biofilm and previously was involved with the development of PDT for treating cutaneous and other cancers while at Roswell Park Cancer Institute. He sees a bright future for PDT in dentistry, providing more selectivity and flexibility when treating patients with early oral lesions and microbial diseases of the oral cavity.

“With the utilization of a topically applied drug, there is a distinct advantage of using PDT, particularly for bacterial and candida species,” he said. “With bacterial and candida lesions, one of the major advantages of PDT is that it provides the practitioner with a method that is easily applicable in an office setting and that can be used to treat various species in a fairly rapid manner. These species take up the photosensitizing drugs very rapidly — we’ve seen effective doses in one to 15 minutes.”

In addition, many of the candida species and some of the bacterial lesions can become antibiotic-resistant, and PDT has been shown to be effective on antibiotic- and antifungal-resistant species, Mang noted. “So while treating the disease, you can reduce the need for antibiotics or supplement the use of antibiotics in very severe cases,” he said.

With cancerous lesions, PDT offers a localized form of therapy that can be repeated, Mang added.

“We have generally not found any buildup of resistance to PDT, so one could have repeated exposures to benefit the patient and reduce the severity of treatment by taking a more fractionated approach,” he explained. In addition, with early cancerous lesions, PDT generally offers improved functional and cosmetic outcomes versus surgical or radiotherapy approaches, while achieving comparable tumor control, he noted.

Growing body of research
Despite its many advantages, topical PDT for dental applications is still a few years from clinical reality, Mang noted (one exception is Periowave; see sidebar). In the meantime, a growing body of research supports the use of PDT for treating oral diseases and eliminating “bad” bacteria in oral biofilms.

For example, a 2007 study in the Journal of Dental Research (August 2007, Vol. 86:8, pp. 694-707) noted that “applications of PDT in dentistry are growing rapidly: the treatment of oral cancer, bacterial and fungal infection therapies, and the photodynamic diagnosis of the malignant transformation of oral lesions.” In addition, PDT has shown potential in the treatment of oral leukoplakia, oral lichen planus, and head and neck cancer, and photodynamic antimicrobial chemotherapy has been efficacious in treating bacterial, fungal, parasitic, and viral infections, the researchers wrote.

More recently, PDT showed promise in the treatment of early-stage cancer of the mouth and oropharynx, and demonstrated that it has a significant antimicrobial effect in the oral cavity (Lasers in Surgery and Medicine, January 2010, Vol. 42:1, pp. 1-8; July 27, 2012).

Now a review in Oral Diseases (September 3, 2012) lends further support to the clinical efficacy of PDT in the management of oral diseases, in this case potentially malignant disorders (PMDs).

“Based on its high efficacy and low side effects, its high patient acceptance/compliance, the simplicity of the procedure, and its minimal pretreatment preparation, topic PDT is believed to have potential to play an important role in the management of PMD, especially for the low-grade dysplasia,” wrote the study authors, from the University of British Columbia and the British Columbia Cancer Research Centre.

More studies neededHowever, limitations remain. While some studies have used topical or systemically administered photosensitizers to treat dysplastic lesions in the oral cavity, none of these drugs has regulatory approval for this application, the researchers noted. And while topical ALA (5-aminolevulinic acid) in emulsion form has been the most commonly used form of PDT for treating dysplastic lesions, there is no consensus with regard to protocol.

In order to bring PDT into the clinical arena as a first-line treatment for potentially malignant disorders in the oral cavity, protocols such as illumination scheme, number of treatment cycles, incubation period of the photosensitizer, light source, and fluence rate need to be considered, as well as lesion size, thickness of the surface keratin layer, and the presence and degree of epithelial dysplasia, the researchers emphasized.

In addition to a need for more studies with standardized treatment protocols and randomized clinical trials, several technology advances need to occur as well, they noted.

“In the future, more compact, cheaper light devices such as inexpensive lasers, fiber-optic equipment, and simple dosimetric apparatus could help in bringing down the initial cost of setup,” they wrote. “In addition, use of new targeted photosensitizers, light sources, and drug delivery systems using nanoparticles could significantly contribute in increasing its therapeutic efficacy and specificity.”

Allow me to relay the experience of a patient who has been through trying times lately. The patient is a middle-age female who noticed a small, firm swelling in the right submandibular region. She had never experienced this type of problem before, but since she had an upcoming visit with her family physician, she thought she would mention it. Her family provider told her it appeared to be a swollen lymph node and recommended she schedule an appointment with her dentist in the event that she had an oral infection.

Being conscientious about health issues, this patient did have an examination with her dentist. He advised her that it was a swollen lymph node, but that there were no apparent oral health infections. He reviewed causes of swollen lymph nodes and felt that since she was asymptomatic; the node simply represented residual effects from a cold or allergy condition.

Over the course of the next year, this patient presented on several occasions to both her family physician and dentist with concerns that the lymph node was getting larger. Both health care providers told her to “forget about it,” or “it was nothing.” She felt uncertain about both individuals at this point, but since they seemed to be in agreement that her condition “was nothing,” she heeded their advice.

After several more months and with ever growing concern, the patient presented to her dentist again for further evaluation. At this point, he expressed the opinion that the patient appeared to be “looking for trouble that wasn’t there.” She went to the reception area and commented on that, but paid her bill and proceeded to leave the office. As she was walking to her car, the office receptionist approached her. She stated that since this was a problem that had persisted for over one year, she thought the patient should get a second opinion. The receptionist did not want to get in trouble, but felt that she needed to reinforce the concept of a second opinion. After all, if after a second opinion, this problem truly turned out to be “nothing,” the patient could rest easy.

After hearing this advice, the patient phoned a university in Philadelphia and asked to have an appointment scheduled. She described her problem, and the telephone operator scheduled an appointment for her to see the head of the ear, nose, and throat department of the university. During her appointment with this specialist, the patient described her concern that the node was growing. She denied other symptoms or problems, but explained that she was worried that there was more than “nothing” with this condition.

The patient related that the specialist took one look at her lymph node swelling and told her she was going straight for a biopsy and to an oncologist. Turns out she had stage 4 lymphoma. Since February 2011, she has been on a rigorous course of treatment and still has six more months of chemotherapy to complete. Remarkably, her most recent PET scan showed that she was cancer-free, and her prognosis is good.

So let’s take a moment and think about the lessons we can learn from this patient’s experience. The first thing that comes to mind is that we need to listen, really listen, when our patients present to us with an abnormal finding. This patient was pooh-poohed rather than reassured. There was no effort made to encourage her to see a specialist or have a biopsy. The lesion did not appear to be aggressive in nature.

We have seen the literature that discourages the use of adjunctive screening devices as part of the oral cancer examination, because these devices do not appear to be better than a conventional oral examination. We have seen the literature that warns we should not be using adjunctive devices because we don’t want to alarm our patients that they might have cancer.

However, this case is different. The patient was already alarmed.

Would our role in this situation be to alleviate the patient’s concern or identify the problem? The patient was delighted to have somebody hear her concern and perform a biopsy. She wanted to be reassured that either this problem was truly nothing or was something, and she would receive appropriate treatment. Instead, this process was delayed for one full year while her cancer spread.

A question for us to consider is what harm would have been done if a biopsy had been recommended when the patient first presented with this condition? She was already alarmed. She wanted to know what was wrong. She would have been relieved to have a confirmed diagnosis. Many of our patients feel this way, even if recommending a biopsy seems frightening. The mere idea of a biopsy can be anxiety-producing. But, knowing vs. not knowing is also anxiety-producing. At what point do we reconcile within ourselves that the best course of action is to biopsy? Why guess when we can confirm?

Mind you, there is no need to play the blame game here. This patient has not spent her time on that as much as focusing on getting well. The health care providers who examined her did not feel there was cause for concern. The patient did not present with obvious symptomatology other than the node. Many people walk around with swollen lymph nodes, and they don’t have cancer. An educated guess was made. Unfortunately, for this one person, the guess was wrong.

Take a moment and ask yourself what is your position on this situation? Would you have gone along with the provider’s recommendation to “forget about it” or would you have recommended taking action?

I ask this question because the patient asked me to ask you. She wanted her story relayed because she feels that action needs to be taken immediately when a patient presents with this type of condition. Her story seems to be ending well, but what about the others for whom diagnosis is delayed until it is too late?

Her message to you is to take a chance and recommend referral for biopsy. If the lesion turns out to be “nothing” or benign, that is perfectly fine. If there is a problem, it is identified early and the patient stands a chance of surviving. And that is so much better than worrying for one year and then finding out a diagnosis of advanced cancer.

I want to hear your stories about this type of situation. It is important for all of us to realize that we can make a significant difference by taking immediate action. Also, it is important for us to recognize that going against the prevailing point of view is not always easy, but sometimes very necessary.

About the author:
JoAnn R. Gurenlian, RDH, PhD, is president of Gurenlian& Associates, and provides consulting services and continuing education programs to health-care providers. She is a professor and interim dental hygiene graduate program director at Idaho State University, adjunct faculty at Burlington County College and Montgomery County College, and president-elect of the International Federation of Dental Hygienists.

It’s a journey that can begin in the mirror or at the dentist’s office.

A small lesion in the mouth or throat can turn out to be oral cancer. Notoriously known to be unpredictable, these cancers are hard to treat, but some young doctors at the New York University’s School of Dentistry are working to change that.

Oral cancers take one American life every hour and it’s because the unpredictability is a challenge. One person’s cancer might be slow growing and another’s wildly aggressive. It is impossible to tell which it is.

The NYU researchers are trying to decipher their instruction codes, their genomics. If doctors know which way the cancer is going, it can be stopped.

Halima Mohammed always carries water she constantly needs to drink. She is also a big consumer of fruits and vegetables. The reason: for nine years she has been fighting an oral cancer.

“I can’t have solid food so I get my nutrition from juices and most of these foods, especially the cabbage and the broccoli, are cancer fighting foods,” she said. The cancer has had a huge impact on her life. She’s already lost part of her tongue.

“It is from my research one of the most painful type of cancers that you can have and I’m not diminishing cancer and the types of cancer, there is a constant pain, constant pain,” said Mohammed. “It makes masticating difficult, swallowing difficult. You cannot have your favorite food anymore.”

But, Mohammed carries on, and now at the NYU College of Dentistry she’s helping the doctors find out more about cancers like hers.

It’s a challenge Dr. Brian Schmdit has taken on. He wears many hats at the school, among them he’s clinical director of the Bluestone Center for Clinical Research and he’s trying to understand more about oral cancers.

“Oral cancers are very tricky because they have highly variable clinical patterns where one patient can do very well after treatment and another patient does not do well,” he said. ”

That different behavior lies in the cancer’s genes and their genomics are the subject of his research, identifying and tracking the genes of the different cancer will eventually benefit patients.

“We’re hoping that it can be personalized, that we can use certain genetic markers in the cancer to tailor our treatment, to know which persons need aggressive treatment and which patients don’t need that aggressive treatment,” said Dr. Schmdit

With information about the cancer’s genes, doctors might be better able to predict who needs radiation, which needs no de dissection and prevent much of the overtreatment that now is necessary.

Oral cancer is found by dentists and patients, so if there is a pain or a ulcer or a suspicious area, get checked out for it.

Packets of chewing tobacco sold across India after December 1, 2011 will have to show graphic images portraying the disfiguring effects of oral cancer, but cigarette and bidi packets may show milder pictures, the Union health ministry said today.

The health ministry has notified two new sets of pictorial warnings — harsher images for packets of chewing tobacco — that will replace the existing pictures, scorpions on chewed tobacco products, and diseased lungs on cigarette and bidi packets.

Cancer and public health specialists have welcomed the new images, but pointed out that the choice of images given to manufacturers of smoking tobacco will allow them to use a milder warning of a man with diseased lungs rather than of mouth cancer.

“I’m not happy at all at the choice of pictures for smoking tobacco products,” said Pankaj Chaturvedi, an associate professor of head and neck cancer surgery at the Tata Memorial Hospital, Mumbai.

“Pictorial warnings need to have a strong deterrence effect that impacts people — the pictures for chewing tobacco are likely to have such an effect, but the pictures for smoking tobacco don’t,” he said.

“The new four pictures for chewing tobacco are very similar and graphically depict the consequences of mouth cancer,” said Monika Arora, the head of health promotion and tobacco control at the Public Health Foundation of India, New Delhi.

But three of the four images for smoking tobacco packets show a male with lungs in different stages of disease, while the fourth image shows a gross lesion on the mouth caused by oral cancer.

“Manufacturers are more likely to pick one of the pictures showing the man with diseased lungs rather than the picture of oral cancer,” a source in the health ministry said.

The new health warnings, due since June 2010, are expected to be implemented by all manufacturers from December 1, 2011. Anti-tobacco activists believe that lobbying by sections of the tobacco industry has contributed to the delay in the new warnings.

The new pictures will be used for two years after which the health ministry is expected to issue a fresh set of pictures.

Health ministry sources said harsher pictures have been selected for chewed tobacco because surveys have shown that more men and women in India use smokeless tobacco, mainly chewing tobacco, than smoking tobacco.